Brief Changes

Instructions
On the following pages is a list of statements that describe children. We would like to know if your child has
had problems with these behaviors over the past 6 months. Please answer all the items the best that you can.
Please DO NOT SKIP ANY ITEMS. Think about your child as you read each statement and circle
N

if the behavior is Never a problem

S

if the behavior is Sometimes a problem

O

if the behavior is Often a problem

For example, if your child never has trouble completing homework on time you would circle N for this item:
Has trouble completing homework on time

N

S

O

If you make a mistake or want to change your answer, DO NOT ERASE. Draw an “X” through the answer you
want to change and then circle the correct answer:
Has trouble completing homework on time

N

S

O

Before you begin answering the items, please fill in your child’s name, gender, age, grade, your relationship to
the child, today’s date, and child’s date of birth in the spaces provided at the top of the next page.